November 16, 2009

In its first reevaluation of breast cancer screening since 2002, the federal panel that sets government policy on prevention recommended the radical change, citing evidence that the potential harms of all women getting annual exams beginning at age 40 outweigh the benefits....

The task force's new guidelines... [also conclude] there is insufficient evidence to continue routine mammograms beyond age 74....

109 comments:

When they say they will emphasize prevention, they don't say of what. Now we know that it is prevention of extended lifespans so that thousands of women won't use medicare or social security. At the same time, it can be a stimulus for the funeral industry, clearly hurting in this economy.

If anyone except the Doctor and Patient make these decisions, we all lose. Prostate cancer screening is next on the list, just live with the cancer, since most of the time it won't kill you.

They can have commercials with smiling people giving thumbs up to the camera with voiceover saying, "Aren't you glad you won't be diagnosed with anything and have to undergo tough treatments?" Then each person individually and enthusiastically says, "I'm glad!" At the end they all get together and yell in unison, "It's nature's way!"

These Harvard idiots arePublic health Uber Alles types that could have run the most efficient concentration camp for the Nazis and never noticed a contradiction in their showing off that they are always right. The collectivist view point of morality has zero tolerance for real individual people making a claim for their right to recieve what they need. With them it's always the average of all that determines your individual fate, and if you don't fit the profile so what, because they rule and have ALL the money. Jeremy Bentham thought up this BS and overeducated fools have fallen for it ever since. Thank God that Sarah Palin has not been mind controlled at Harvard.

"It's not a Death Panel. It's the Efficiency Panel." It's just some times the most efficient use of money is not providing care and allowing many to die since to save them is too costly. Under socialized medicine you get to do more hoping: first you hope there's a cure for your disease, then you have to hope it's cheap. Hopeychange everyone!

Elliott mentions that prostate cancer screening will be next, but in fact there is good reason that it should be. Surgery for prostate cancer is itself quite dangerous, and PSA tests have a high false positive rate. So it is quite arguable that agressive screening costs more lives than it saves.

Really, though, deciding when preventive screening pays off is a hard problem. What scares me the most about ObamaCare is that we will end up making these kinds of decisions with a one-size-fits-all rule from on high, without the benefit of continued experimentation which is what moves the science forward.

"... the federal panel that sets government policy on prevention recommended the radical change, citing evidence that the potential harms of all women getting annual exams beginning at age 40 outweigh the benefits."

Got that: The "potential harms" outweigh "actual benefits."

This is nothing less than a death panel.

Remember ladies ... this is your unicorn hero Barack Obama sacrificing your breasts on the alter of government cost-cutting. His need to placate the Chinese debt market outweighs your need to control your own body.

First of all the quote Althouse highlights is...strange. The guy's a professional, asked to speak in his area of expertise, and what he gives us is, in order:

1. A statement that assumes the conclusion. Whether lives are saved overall by universal mammograms from age 40 is what's in controversy, but he doesn't offer an argument, just an assertion.

2. An insult to the people disagreeing with him.

3. A mischaracterization of the disagreement. (The feds are not recommending "doing away with" mammograms, they're recommending doing fewer of them.

There are real harms that result from false positives on screening tests - everything from anxiety and stress to disfigurement and health problems resulting from unnecessary treatment. At a certain point, if the likelihood of finding a real cancer is low enough, those harms outweigh the benefit of early treatment. (Random example: suppose doing a mammogram every year had a 20% chance of finding cancer, resulting in possible longer lifespan. You'd probably do it. Now suppose it's a 0.02% chance. Probably not.)

At the end of the day this is all statistics. If you take two equal populations of women, give one group yearly mammograms starting at 40 and going on forever, and the other group biannual mammograms starting at 50, which group has better health, longer lifespan, and other benefits? If it's the second group, and if the benefit of fewer mammograms is clear enough, there is really no justification for recommending or requiring more frequent testing.

Notice, please, that I haven't said a word about money thusfar. This is all about medical benefits and drawbacks.

This is the problem:under health-care reform legislation pending in Congress, the conclusions of the 16-member task force would set standards for what preventive health-care services insurance plans would be required to coverThe problem isn't that this task force is doing what it's supposed to do, making recommendations based on medical science. The problem is that once the federal government takes over medical care, those recommendations start having force of law, and aren't recommendations at all any more. That's a problem whether they're defensible scientifically or not, because it takes decision-making away from the person whose body it is.

But Professor They're-All-Idiots wasn't complaining about that, and I have no doubt he'd say the same thing about any influential group that released such recommendations.

There actually is much evidence that mammograms help with breast cancer. The rapidly growing breast cancers that do kill usually develop between mammograms.

Slow growing cancers will be detected, but whether these are clinically significant is debatable.

With a 10% false positive rate with mammograms, after 10 of them the likelihood that you'll have a false positive is about 75%. This means that almost everyone who has regular mammograms but never develops breast cancer will probably undergo some invasive procedure to rule out cancer

And of course, as far as unnecessary, overly expensive, and potentially harmful procedures go, we all know one easy step to take to dramatically reduce them, but the democrats blatantly refuse to even acknowledge the issue because trial lawyer money is more important to them than all the crocodile tears they shed over the healthcare 'crisis.'

Storkdoc and Jaed are correct. Statistically, mammograms provide little benefit for populations over 75 and under 40. However, we've spent the past 20+ years emphasizing the importance of mammograms and early detection and prevention. It's going to be nigh on impossible to roll that perception back. The bottom line is, if you want to have a mammogram when you're under 50 or over 75, you should be able to- though you will probably have to pay for it yourself. Is that asking too much?

I would just ask, storkdoc, kill when? As someone diagnosed with her second mammogram, at age 41, I'm happy to have enjoyed years of checkups and procedures. Two friends added 10 years to each of their lives by early diagnosis.

So, in the collective, cutting back sounds good--and will save Obamacare lots of money. But individually, it's a death panel.

Jesus Christ, Florida, what is your malfunction? Did you miss what came right after "anxiety"? Health consequences, disfigurement? Do you think these don't matter?

This is statistical. It's not personal. More mammograms mean more correct diagnoses, and some of those diagnoses will save lives. They also mean more false positive diagnoses and thus more medical problems caused by the testing itself, and some of those problems are not trivial.

It's true some women are diagnosed in their forties. But then some women get breast cancer in their twenties as well. We don't have universal mammograms starting at age 15, even though they would turn up some cases of breast cancer and probably save lives. This isn't because of the money but because of the medical consequences.

There have been studies that indicate mammograms don't provide any increase in longevity whatsoever. I'm all for people getting the tests they need, but this isn't as cut and dried as people are trying to make it.

Obama-Pelosi Health Care PlanMedical Home Pilot Program House Bill 3962

The bill creates a pilot program to set up "Patient-centered medical homes". These homes will furnish "medical care services to beneficiaries...and to targeted high need beneficiaries. See Sec 1302(a)of House Bill 3962; it amends the Social Security Act by adding new section 1866(F). See Sec. 1866F(a)(1)at Sec. 1302(a)

"Patient-Centered Medical Home Services" means "services that coordinate the care provided to a beneficiary by a team of individuals...as needed and appropriate; See Sec. 1866F(b)(1)(B)

The term also means "to take responsibility for appropriately arranging care with other qualified physicians or providers for all stages of live;" See Sec. 1866F(b)(1)(C).

"Targeted High Need Beneficiary" means "a beneficiary who, based on a risk score as specified by the Secretary is generally within the upper 50th percentile ok Medicare beneficiaries. See Sec 1866F(c)(1)(C).

I was thinking it was the administration's first foray into direct support for dead-tree media. The NY Times will fill miles of columns with news and commentary on these trials, and Islamists all over the world will eat them up.

I don't have breast cancer risks in my background or in my family's background. Not a single female ancestor (or their sisters) have had breast cancer for the past 4 generations. I have their death certificates.

Like a good little girl, I had a mammogram when I was 40. There's no way I will ever have another one unless a manual exam suggests there's a good reason to.

This doesn't mean I won't ever get breast cancer, just that I'm not going to go look for something that is statistically likely to NOT be there.

I'm certainly not against screening tests, but to prescribe them on a regular basis to a population without a known risk factor seems quite wasteful.

Some of that money would be well-spent on developing a screening test for ovarian cancer. And some of it better spent on developing treatments that work better.

There are women who should have regular mammograms starting in the late teens. These women can be identified by genetic testing and I'd much rather money be spent on that.

mebbe so. Not the point. The gubmint gone tell you what you can and can't have.

And oddly, all de studies will show that all de tests for all de olden peoples ain't as cut and dried as people are trying to make it, and so won't be covered no mo'.

So what are you proposing? We keep doing expensive tests even though the data says they aren't worth doing?

I'm not thrilled with the idea of government care either, but in this one instance, at least, the anger is misdirected. The only reason Congress even chartered this commission is they need somebody to explain to women why they should keep taking a test that won't make them live longer.

If they can't show the importance of regular breast exams for 40 year old attractive women, which must include showing the whole procedure, then what are they going to do during sweeps?

The medical necessity of showing breasts on television is the number one reason why prostate cancer research is not as well funded. Because, no one wants to see that. Well, maybe not 'no one', some people have a very different interests than I do.

Henry, it appears that you're arguing this: If you give 1000 women mammograms, and you deny 1000 women mammograms, then more of the women who receive the mammograms will die, because of complications from biopsies that are needed because of false positives, and because some of the women will, I guess, catch something at the hospital while waiting for their mammogram...than will die from cancer in the second group.

What is somewhat amusing about this is that in many, if not most, states most private health insurance only routinely started paying for annual mammograms due to government mandates.

Wisconsin started requiring this in 1990.

So now, a couple decades later we start to see some evidence that perhaps this is not really something that will benefit most women. What do we do? Do we base coverage on evidence or a sense of entitlement?

Since we didn't have blogs back then if we look at letters to the editor from a couple decades ago would we see the same sort of uproar over government intrusion into health care in REQUIRING mammogram coverage as we see here now in the comments of those who want stop the government from even suggesting that perhaps that annual requirement is possibly doing more harm than good?

Women would still be able to have all the mammograms they want. What might change is that they may have to start paying for them themselves just like back in the good old days before government got involved in health care.

Isn't this type of analysis performed now by private and public insurers today?

All insurers only insure and pay for "medically necessary" procedures. The question is what is medically necessary as appropriate care for potential breast cancer, i.e. is an annual mammogram medically necessary for all women from the time they have developed breasts until they die.

I don't think anyone would deny as medically unnecessary a mammogram at any time to a woman who detects a lump or other abnormality upon examination by a nurse or doc, or by self-examination verified by a nurse or doc.

But does a woman like DonnaB, who has no apparent problems and no history of breast cancer in four generations, have a medical necessity for annual mammography from puberty until death?

The medical science has always supported this. It was pure politics which made the age 40. As for the harm, there are women who have died due to false positives and women who have gotten breast cancer as the result of being irradiated. Mammogram screen is VERY oversold as a diagnostic tool (breast self-exams are even more oversold.)

@Pastafarian -- know one knows the answer to your question. The data simply isn't there -- at least not in the articles I've read. Some studies have compared overall mortality of screened and non-screened populations, but I don't believe this is the case for mammograms.

First, because of the number of commenters that assume bad faith on the part of the medical experts that created these guidelines.

Second, because of the assumption that cost doesn't matter. Cost does matter. Cost pushes people out of the expensive preventative-healthcare-based plans. They either buy catastrophic coverage (if it's legal in their state) or go without coverage at all. Cost determines how far the capital goes in terms of research, equipment, and education.

I am not a supporter of the current healthcare proposals. The key risk is not that they'll cover too little, but cover too much -- that is what government benefit programs do. When you couple the high premiums that will result with the reassurance that anyone with a preexisting condition will be covered, you create a strong incentive for people to avoid coverage altogether. It will be more affordable for people to pay the fine for not having coverage when they can simply wait until they are sick to sign up.

When I go to a doctor, I want to hear the costs and benefits, risks and percentages of any test or treatment. I don't take anything for granted.

But you know what? It's none of my damned business. I don't have breasts. Leave this cost-benefit analysis up to those who do.

...or those whose tax dollars are subsidizing a public option that is paying for it, or who are coerced into subsidizing it because their state government requires all insurance plans to cover mammograms that are not otherwise medically indicated.

"Eric said... So what are you proposing? We keep doing expensive tests even though the data says they aren't worth doing?

You are still missing the point.What's this we shit, kimosabe?When did my healthcare decisions become the gummint's? It's a matter of choice.In Obamacare, the choices are made for you.In effect, the gummint owns you. It alone decides what care and drugs and tests you get.You may find that gives you a tingle up your leg.It makes me want to slit some throats (ala Mencken).

"I'm not thrilled with the idea of government care either, but in this one instance, at least, the anger is misdirected."No, no, no.This just isn't any of the gummint's goddamned business.

I will second what Joe said, this is not news. I'm a physician and I've taught screening evaluation to medical students. We've know this about under 50 mammo's for some time.

First, remember the general mammogram recommendation pertains to all women, average risk. With that in mind the key questions to ask of ANY screening intervention are:1) Will the results of the screening test allow you to treat the patient better (meaning fewer deaths or less morbidity) than clinical symptoms will allow? 2)Is the test reasonable in terms of cost, patient acceptance and clinical feasibility?

Now mammogram has demonstrated by and large that it passes the second test. Though few woman enjoy having their breasts squeezed in a variety of directions, my experience (and the experience of researchers) would say its generally "ok" for women.

Its the first test where mammograms in average risk women under 50 have struggled. Among the reasons that may be so are:-lower incidence of breast cancer in that age group and therefore more false positives-more difficulty in reading "pre-menopausal" mammograms-"pre-menopausal" breast cancers "behave" differently and may respond differently to the "typical" treatment we offer women of 50 found to have breast cancer by mammography.

This was not "thought up" by the Obama administration. I assume all insurances, Medicaid and Medicare will continue to pay for screening mammography in women under the age of 50. The politics and public sentiment are so strongly against any effort "against fighting breast cancer".

And since it was mentioned, yes it's not possible at present to say that ANY screening test for prostate cancer will allow men who might get prostate cancer in the future to live better or live longer. However, the reasons are slightly different.

Finally, NEVER assume that an unnecessary biopsy on a non-cancerous breast is risk-free, especially when you consider that MILLIONS of women will get such a biopsy (as a result of screening recommendations).

IIRC 85% of women with breast cancer don't have a family history of breast cancer.

Other risk factors:

Nulliparous.Didn't breastfeed.Didn't have children until 30 or later.Long-term use of hormonal contraceptives--five years lifetime use or longer. Sheeit, the average American woman has that racked up before she graduates college. Also partly explains the explosion in breast cancer diagnosis in ever younger women.HRT use. This is already known and as women en masse stopped using HRT, brCa in that age group declined.

OK if no mammogram, free annual PET CT scans for everybody! Detect almost any cancer--why limit yourself to BrCa screening?

A PET CT scan detected my BrCa, when mammography didn't, and I could never feel it even after I knew where it was mapped. The ma'amgram was 2-3 months before the PET CT. My tumor was very fast growing and heinously aggressive--grew 1 cm in 3 weeks. So maybe it wasn't developed enough to see when I was ma'amgrammed.

Still, I am grateful for the great good luck at having a PET CT scan for another entirely different reason...and oops surprise surprise. My thyroid oncologist ordered the scan for ongoing monitoring of a low but stable ThyCa cell count in my blood stream, just to make sure it wasn't setting up camp anywhere. Cancer for me is a chronic condition.

I'm steeling my nerves for the Efficiency Panel to notify me that I'm a statistical freak for having three cancers and that I've used over two standard deviations above the mean lifetime health care budget and therefore will no longer be eligible for anything but maintenance and palliative care.

Notice NO BILL defines health care as an INDIVIDUAL RIGHT of the citizen. That's just pretty talk for campaign promises and pillow talk.

If it were a right, we could sue the government for violating our rights when they deny care.

There are real harms that result from false positives on screening tests - everything from anxiety and stress to disfigurement and health problems resulting from unnecessary treatment.

Jaed, as a woman who has had not one, but two breast abnormalities - one in her teens which required surgery and one in her 20s which, thankfully, did not - let me tell you that you are WRONG.

I am not some fragile little figurine who needs to be sheltered from a false positive. Stress happens - I felt that stress while waiting for a diagnosis. You know what is more stressful, though? Not getting medical care. I had to fight like the devil, both times, to get doctors to diagnose me and treat me. After the first incident, my second physician said, "I don't mean to disparage my colleagues whom I've never met, but I don't see how he could have said that this wasn't an issue; everyone can tell that there's a tumour there."

Thankfully, I got a second opinion, because the thing had to come out. (It actually doubled in size, to over an inch in one direction, by the time it was removed.) In your world, though, the "stress" of a "false positive" would mean that the 19-year-old version of me would have to STFU and not get treatment, because very few 19-year-olds with palpable lumps end up with cancer.

Is "screw you" an inappropriate response to such paternalistic, patronising bull?

Is "screw you" an inappropriate response to such paternalistic, patronising bull?

I would NEVER want to discount an individual's experience with illness or the health care system but you can see why I say The politics and public sentiment are so strongly against any effort "against fighting breast cancer"

As for this absolute ridiculousness of avoiding screening because of potential disfigurement: first of all, I will not die because some chauvinist thinks that I need to be protected from the horror of having slightly imperfect breasts.

I happen to also know, again from experience, that biopsies and lumpectomies do not cause disfigurement. Sure, one breast is slightly smaller than it used to be, but the scar is invisible and the only way that someone can tell is if they stare at my unclothed breasts. Anyone in that position should be too busy considering himself to be damn lucky to complain about any imperfections = and imperfections, not disfigurements, they are.

Finally, even assuming that lumpectomies and biopsies are so disfiguring as to cause fragile, gentle, tender-breasted women all sorts of neuroses, we live in an age of some pretty amazing boob technology. If a woman is to the point that having slightly "disfigured" breasts would be as bad as cancer, then she needs to find herself a plastic surgeon and have the best of both worlds.

so disfiguring as to cause fragile, gentle, tender-breasted women all sorts of neurosesHappens all the time on the Lifetime network, but it began with Miss Ellie on "Dallas."

But seriously, I (willingly) was thrown off a civil jury in '91. A woman was suing a doctor who falsely told her she had cancer. Two weeks of angst before she went for a second opinion.This was 3 months after I'd had a melanoma cut off my leg, so I wasn't sympathetic.

First off, ITA with Pogo that I don't want these kinds of recommendations from a panel study turning into laws and regulations backed up by government enforcers.

That said, I know from personal experience that mammography of pre-menopausal breast tissue is simply not that effective. The breast tissue is too dense, and even if the technician maximizes the squashedness, the radiologist isn't really going to be able to "see" what's going on in the dense breast tissue. So there's no point in ordering mammograms from the time breasts develop, or even from, say, 30 years on. If a 30-year-old needs to be examined for breast cancer, there are much better tests, including ultrasound or as KentuckyLiz discovered, PET/CT, which is excellent at finding cancers that a CT scan alone would miss.

Waiting until 50 to start bi-annual mammograms probably isn't such a bad idea for women with no family history or other risk factors. The problem is, again, is this a recommendation that you can discuss with your doctor, or is this a dictate that is handed down by the government? That makes all the difference in the world.

This is about money, I think. The most common follow-up to a funny mammo in young women with dense breasts these days is an ultrasound, an MRI, or even an MRI with contrast. While ultrasounds are cheap, the MRIs are beaucoup expensive.

It's unusual for a combination of mammo and MRI not to give some pretty good answers, and if you follow that up with a needle biopsy, which is painful but hardly dangerous or disfiguring, then your chances of knowing whether or not you have a malignancy are very good.

But keep in mind how expensive that follow-up to false positives is. That's the real problem, folks. It costs a lot of money to be sure you don't have cancer.

If it's your money, then you can make that decision, or not, based on what your radiologist tells you. If your money for health care has already been taxed away by the government, so they can generously give it back to you, ha ha, as "free" health care -- well then, I'm guessing it will be a panel like this that decides for you. And we can be pretty confident in the coming decades that saving money will be the Number One priority.

Oh, and my wife was diagnosed with Stage I BC three years ago, at age 43. Anyone want to guess how far along the tumor would've been had her first mammo occured at age 50, assuming she even lived that long?

Pardon me, but in Britain, women don't get yearly mammogrammes. Too expensive for the system, and the "data" is inconclusive.

What a shock that this is coming out at this moment, this utterly nonsensical, highly irresponsible finding by the federal commission, at the very moment when America seems poised to enter the socialised health care business.

'Cause, you know, you don't want women logging up the queues for their freebies at the health clinics.

BTW, my liberal father who is in favour of the NHC in any country (and who happens to be a medical doctor), called this. He told me about 6 months ago that we will soon see JAMA and other medical entities revising their advised health exams schedules. It would just be too costly for the State, like C-sections which no one in Britain has.

I share the politics of many of this sites readers, but I don't think this is as conspiratorial as many of them assume.Screening for disease in a healthy population is problematic in many ways. Applying an imperfect screening test with a relatively low predictive value to a population with a prevalence of disease less than 10% can be expected to yield a false positive rate of more than 50%. That's a lot of radiation, negative biopsies, and unnecessary lumpectomies. These carry the burden of both cost, and morbidity. Simply put, the best way to minimize false positive tests is to either develop the "perfect" test, which never misses a cancer, nor diagnoses one wrongly, or, to apply your imperfect test to a higher risk population.I'm a cardiologist, and we run into this issue in doing screening stress tests on young, relatively low risk patients. Look up "Baye's Theorem" on wikipedia for a better explanation. Anecdotal stories aside, the evidence for mammography actually prolonging life is controversial.(Look up "lead time bias.)Some women get breast cancer in their 20's and 30's. Should we screen them too? of course not, because the incidence is too low in this age group. For women in their forties, it's a closer call, but the logic is the same. Love your website, Ann. Keep up the good fight.

Heh. One of the reasons voters in NJ were supposed to vote Corzine is that he and Obama would ensure mammograms were covered by the insurance companies...They never said anything about the government, so maybe it wasn't a lie...

I just read the Annals of Internal Medicine article. It's BS. Basically they say "we've thought it through and these are our recommendations". No description of methods. Not even referenced with a suprascript linking to a footnote. Maybe, buried somewhere in the references you could scrounge up the methodology, but they didn't lay it out to be seen and judged.

Just an edict.

I just had a 42 year old breast cancer patient tell me yesterday: "Thank God for mammograms"

If you want to get a bunch of women riled-up, just try making it harder to fight breast cancer. The Pink Ribbon gals, and their husbands and boyfriends and supporters, number in the hundreds of thousands (millions?), not tens and twenties like Code Pink.

The new guidelines also recommend against teaching women to do regular self-exams

Can someone tell me why the hell they would recommend that people NOT do self-exams? Because they might come in to get something checked if they find something?

About 39 million women undergo mammograms each year in the United States, costing the health-care system more than $5 billion.

This is why I hate the national health care push. Because it doesn't cost the "health-care system" money, it costs individuals and companies who share in the pay for insurance. Making it cost the "system" money makes it so people think that it's everybody else's business what they do with their own doctor.

The scary thing is that preventive medicine does not save money at all. People live longer and money gets spent on other health care matters that far exceed any taxes paid because you were still alive or not disabled by illness.

That would be a concern only if money were the most important factor in making a decision about medical care.

And now we are drifting to a state of affairs where that will in fact be true, and money will be the only factor, though gussied up as QALYs or some such nonsense.

Again, those who argue that the utility of mammography is in doubt are missing the point entirely.

The issue is power.The issue is choice.When the government has the power, they determine your choices.

The state will frame the decision in a way that makes it look entirely reasonable (and might be, were one individual to make such a decision). But when the state makes a scientific recommendation have the force of Law, it begins to delete those citizens who are too much of a burden.

Once you hand over this power to the gummint, they own you. They alone get to decide what care you have access to. There is no way to avoid this except by refusing to give them the power.

Mammograms produce false-positive results in about 10 percent of cases

There's a way to reduce that. You change your decision threshold (i.e. be less aggressive about flagging a suspicous signal). If you do that, however, you also raise the false negatives (i.e. you miss more real tumors) and then you get your ass sued. It's not your fault, there's no way to fool decision theory, but you get your ass sued nonetheless.

A mammogram is a rather insensitive test. MOST cancers, by the time they are discovered (after lingering on the mammogram for an average of five previous years)can be reliably detected on LAST year's mammogram.

An MRI of the breast is more than 90% sensitive in finding invasive ductal carcinoma (the most frequent type of breast cancer); why don't we screen with breast MRI's more frequently?

The government claims breast MRI is too sensitive and would lead to higher costs due to unnecessary biopsies and reexaminations.

This will be the government's tact from now on. Limited resources mean that optimal care and intervention needs to be weighed against the overall cost to the system.

However, the tort system goes unchanged and continues to hold practitioners with a large gun, the sights of which are aimed at the infinity of perfect outcomes.

"The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. "

Specifically, women who are in a high risk group (i.e. family history of breast cancer, especially early onset) may want to get screening, and can. Other women in this age range are at very low risk for invasive breast cancer. Cancers that are detected are much more likely to have never grown to cause symptoms or death. Therefore, screening is much more likely to lead to the unnecessary surgical removal of part of the breast than save a life.

I'm a radiologist, I read mammograms regularly, and I disagree with the findings of this committee. I'm pretty much with Dr. Kopans, whose book I read cover to cover in residency. Waiting until tumors are palpable implies at least another Stage worse in the tumor when diagnosed. More women will die if this becomes standard practice.

I didn't vote for Obama, I even held my nose and voted in the Democratic Primary for Hillary Clinton, something I never thought I would do. The current President is not my choice, and I find him fantastically wrong about a variety of issues.

That being the case, this is nothing that the President signs off on, and does anyone think it would be appropriate for a lawyer (even a Harvard Law Review lawyer) with no experience or training in public health or statistics to slam down this panel?

The larger problem with efforts like this is that they will continue under the current House & pending Senate legislation and no President that follows will be in any better position to legitimately stop them. The President is pretty much divorced from this issue, because he has no grounds to contest the findings. This group throws a bunch of chaff in the air, and the signal-to-noise ratio for when women should be screened goes way down.

The Congress hasn't done this, the President hasn't done this, the "experts" have done this, based on computer modeling (AGW, anyone?) and this does completely obscure the fact that there is not consensus on the issue even among the experts. Now there are two official-sounding groups that recommend screening at age 40, one that says 50-74 only, and another that might revise to something between the two. Spectacular! See, that's the kind of choice that consumers want, iddnit?

The commenter with the sterling family history should be aware that if she had a first-degree relative with breast cancer, her odds of getting breast cancer are 7x higher than normal. But if she has "extremely dense" or "heterogenously dense" breasts by mammographic assessment, her odds of developing breast cancer are 6x higher than normal, even without any family history. She sounds like a person who takes her health seriously, but this study has only convinced her that if it didn't happen to her ancestors it won't happen to her, and that's not the signal she should have gotten from the medical profession regarding her risk. There are better tools than death certificates to calculate breast cancer risk. A GAIL score is one.

This report is a mistake. The "disfigurement" that comes from an ultrasound-guided biopsy is the kind that you can't even see after two weeks, the amount of tissue needed to make a diagnosis in the vast majority of cases is the size of a small french fry in the case of Mammotome or other vacuum-assisted biopsy, or a full stick of mechanical pencil lead in the case of a core biopsy. As a radiologist, I do my best to see that the least amount is done to get a result, and the only people making it to the OR already know they have breast cancer.

Yes, there are probably some types of DCIS that could be watched rather than excised, but at the present time there is insufficient ability to distinguish between the two. That is insufficient reason to stop looking as frequently for DCIS.

As a public health epidemiologist I can understand where the public health people are coming from. As cruel as it may sound, public health epidemiology is in fact quite accurate and does form a good basis for public health policy decisions.

The difficulty, of course, is the public health epi figures while accurate, are accurate for the population as a whole and not for the individual. If you are the person with cancer and an outlier in terms of the population as a whole, you really dont give a damn about the population as a whole. Docs treat the outliers.

One's willingness to go through screenings, even with an elevated rate of false positives and the possibility of subsequent testing, seems to me to be best left to the individual in consultation with the physician.

My PSA went from 0 to 34 in 14 months, and the biopsies confirmed a grade 7 stage 3 cancer which had spread outside the prostate envelope. I had a TURP, followed by radiation, but my little malignant friend is still with me. Without the screening I suspect I would be dead now--even though the public health people (like myself) can tell you why prostate screening fails to meet cost benefit criteria. As others above have pointed out, these decisions are best left to the individual to make and thus my concern with (even more) government involvement in health care.

An MRI of the breast is more than 90% sensitive in finding invasive ductal carcinoma (the most frequent type of breast cancer); why don't we screen with breast MRI's more frequently?

In part because an MRI machine can screen about one patient an hour, and a digital mammography machine can screen six in an hour. Digital mammogram units cost less than half of an MRI, can accomodate a wide variety of patients (e.g., patients with pacemakers cannot have an MRI, overweight patients cannot have an MRI, claustrophobic patients, etc.), and there no need for the intravenous contrast required for MRI. A few people will have spectacularly bad allergic reactions to the gadolinium.

That, and there is overlap between normal physiologic processes in women with an active menstrual cycle and findings that may indicate early malignancy. Screening with MRI is likely to result in more biopsies and for that reason it is only recommended for people at high risk of development of breast cancer.

One's willingness to go through screenings, even with an elevated rate of false positives and the possibility of subsequent testing, seems to me to be best left to the individual in consultation with the physician.

This is exactly what the recommendations do. They say, screening mammography among women younger than 40 probably causes more harm than good, but each person should make this decision based on their own values.

Screening with MRI is likely to result in more biopsies and for that reason it is only recommended for people at high risk of development of breast cancer.

So, you accept this limitation on screening, but do not recognize that the same principle holds for mammography among women between the ages of 40 and 49? This is not a high risk group, and individual women with a higher risk profile will still be screened if they want to be.

Triangle Man--I did leave out one important point in my 9:45: the reimbursement system must accommodate those who are more risk adverse. I am concerned that any bureaucratic system does not handle exceptions very well.

I did leave out one important point in my 9:45: the reimbursement system must accommodate those who are more risk adverse. I am concerned that any bureaucratic system does not handle exceptions very well.

I agree. These recommendations are supposed to provide the best information available to help guide decisions made by patients and their physicians.

If Darren Duvall is still around, I wonder if he would be willing to post the number needed to treat (NNT) for women 40 - 49. In other words, among women age 40 - 49 who have screening mammography, how many need to be treated for cancer to save one life?

I accept the mathematical limitation on screening because if you run an MRI 24 hours a day you cannot screen half the number of women you can screen in an 8-hour day with digital mammography. Digital mammo still has some tricks that are still in development, like digital tomosynthesis and contrast-enhanced subtraction that may be able to do at far lower cost what MRI does today.

MRI does not detect cancer, it detects enhancement after the administration of contrast, and differentiating normal from abnormal is no more clear-cut than with mammography, and can be harder.

I also accept the practical limitation on screening because I read breast MRI and nobody who reads breast MRI for a living recommends it for the general population. The false-positive level is much higher with breast MRI compared to mammography, so it seems to be best suited to people in whom the pre-test probability is already high, like people with the BRCA1 or BRCA2 mutations, or people with family history that is strongly suggestive of same.

Breast MRI is not useless, but it has pluses and minuses like every other test, and the trade-offs do not suggest that using breast MRI as a widespread screening tool will reduce the number of interventions necessary to tell a woman that she doesn't have breast cancer. Tests need sensitivity AND specificity to be useful in a screening situation, and breast MRI for screening lacks specificity compared to mammography.

While reading a book during one of my loooong chemo treatments in my doctors office, the book stated that the treatment for breast cancer, radical masectomy, had not changed in over 200 years. The only progress made was in early detection.

Theo;so, in your world, my otherwise legitimate health issue has morphed into a Womyn-hysteria-fest. No, as I stated I have no intention of discounting or demeaning anyon'es individual experience. But if I was asked would screening ALL women under the age of 50 with annual or biannual mammo's save lives or improve health outcomes (as compared to "routine" care) I would have to say "no". that answer is not acceptable in today's environment.

fls;theo's experience shows the folly of practicing one-size-fits-all medicine.the point was what should be recommended routinely for ALL women under 50. As the USPSTF notes, individual considerations should always enter into a discussion between the physician and his/her patient.

Carl;This is about money, I think.I believe the study and previous studies were not so much concerned with cost but with screening effectiveness. But now that you mention it, yes, its about cost too. COST IS ALWAYS AN ISSUE. we don't have unlimited resources. and cost should be considered in medical decisions. I'm sure many/most patients do it with a medical decision (i.e. "Do I want to go to the ER for this cough and spend 5 hours and $125 co-pay?"). I'm sure most doctors consider cost (i.e. "What should I charge for this biopsy procedure that covers my overhead and gives me the income I desire?") and I'm sure all employers consider cost when putting together their employees health benefits ("Can I afford to bear that additional cost and is so should I buy the low out of pocket or high out of pocket max for my employees?)

Is there some economic transaction that you're aware of where cost is not an issue?

Shanna;Can someone tell me why the hell they would recommend that people NOT do self-exams? Several studies have demonstrated that women who practice breast self exam don't have better health outcomes related to breast cancer than those who don't. Same thing with testicular self exam. Does that mean we should discourage them? No. but based on that I wouldn't put a lot of resources into teaching BSE.

The first thing that came to mind was an old Vietnam story… the geniuses running the war stopped sending cleaning kits over for M16 users because the manual said they were ‘self cleaning’… ergo, who needs a cleaning kit when the manual says…. You know, in a tropical area fighting in the mud and such…

It’s the same moronic ‘I know better than you’ (and your doctor… who is actually in the field…. doing the work) mentality.

Oh well, we needed to elect leftists to be reminded of what they're like...

IIRC 85% of women with breast cancer don't have a family history of breast cancer.

Other risk factors:

Nulliparous - does not apply to me.

Didn't breastfeed - does not apply to me.

Didn't have children until 30 or later - does not apply to me.

Long-term use of hormonal contraceptives--five years lifetime use or longer - I used them for less than 3 years.

HRT use - I tried the pills for about 3 months, but when I asked my doc why they tasted so bad and she told me it was because they were made from pregnant mare's piss, my gag reflex wouldn't let me swallow another one. I never tried another delivery method.

So you see, with my "sterling family history" (as another poster put it) and the almost complete lack of other risk factors, I stand by my decision to not have regular mammograms.

I honestly think they are a waste of time for me and waste of money (no matter whose.) And, as a matter of fact, I don't need the risk of more radiation. I try to take all my health needs and problems into consideration.

In your case, a false negative disaster was averted accidentally. And that's a great and wonderful thing!

Maybe you and my husband should talk. He's had three separate cancers also.

As so many have posted, it's a matter of choice, being informed, and retaining the power to decide for yourself with your doctor.

Given that 7 out of 8 women do not develop breast cancer in their lifetimes, maybe that is the most important statistic of all, and the one that supports your conclusion the best.

Your risk factors do seem very low.

The bigger concern that I have is back to the signal-to-noise ratio. Not many people will seek out the whole story on this, I am afraid that the net message to most women who hear about this will be "you don't need a mammogram", without all the other qualifications.

Darren--Are you really a radiologist who reads breast MRI? Because A LOT of things you state are egregiously WRONG.

It isn't worth my time to refute you with all the data here ...but

Suffice it to say MRI is really really good at finding breast cancer and if you don't know that maybe you should be reading novels or something.

If finding cancer is what we want to do then we should be using MRI. Period.

If screening large populations is what we want to do at the least possible cost (i.e mammograms) then the tort system should be changed so that physicians are not held to the highest possible outcomes by a test that is insensitive and nonspecific (mammography).

But most importantly, the choice of screening exams should be given to the individual informed patients and let them spend their health care dollars the way they feel are best for themselves. We don't need ill-informed professionals or doltish governemnt panels calling the shots for individuals when it comes to their own health.

Donna;Mr. Duvall - I think that's exactly what this study was saying -- that 87.5% of the time, a mammogram is useless.

No it wasn't saying that. No screening test is 100% "right" all the time. If that were so then there would be no need for the test (i.e. the doc knew it would be positive). You expect "a lot" of screening tests to be "normal". The bigger question is what does that "negative" test predict about your actual status and likewise for the "positive" test.

And that's just talking about the test. It says nothing about the disease screened for and its responsive to treatment in the "early" stage.